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Airway-Clearance Therapy Guidelines and Implementation

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Airway-Clearance Therapy Guidelines and Implementation Airway-Clearance Therapy Guidelines and Implementation Mary K Lester RRT and Patrick A Flume MD Introduction What Is Airway Clearance? Cystic Fibrosis Pulmonary Guidelines Implementing the Airway-Clearance Therapy Guidelines Implementing Airway-Clearance Therapies: A Timeline for the Newly Diagnosed Patient Implementing ACT: The Patient Who Transfers to Your Center Implementing Airway-Clearance Therapy: The Hospitalized Patient A Role for Exercise Summary The clearance of secretions from the lungs of patients with cystic fibrosis (CF) is an important compo- nent in the fight to preserve their lung function. There is excessive inflammation in the airways of these patients, which is thought to be exaggerated by ineffective mucociliary clearance and bacterial infection. In 2005 the Cystic Fibrosis Foundation formed the Pulmonary Therapies Committee to review all of the medical literature on the various airway-clearance therapies used in treating CF lung disease. The recommendations were: an airway-clearance therapy should be performed by all patients with CF, no form of airway-clearance therapy stood out as being superior to another, and that patients may express a preference of one therapy over another. They also concluded that aerobic exercise is beneficial to patients with CF, as it is to everyone, and that exercise should be a component to the overall health routine of patients with CF. The challenge for respiratory and physical therapists together with the patient/family is to develop a plan of attack through the use of various airway-clearance therapies. The respiratory and physical therapists are integral in helping patients and families develop airway- clearance routines that aid in the removal of the secretions that cause airway obstruction. There is a wide range of airway-clearance therapies that therapists can choose from when they are teaching the patients and family members the strategies of secretion removal. The questions are: What therapy is best for what age or stage of lung disease? What therapies will the patient do? And which therapies will be covered by medical insurance? These are all fundamental questions that must be answered when guiding families in finding therapies that are effective and appropriate for each CF patient’s unique situation. Key words: cystic fibrosis, airway-clearance therapies, secretion removal, airway-clearance teach- ing, airway-clearance guidelines. [Respir Care 2009;54(6):733–750. © 2009 Daedalus Enterprises] Ms Lester presented a version of this paper at the 43rd RESPIRATORY Mary K Lester RRT is affiliated with the Departments of Respiratory CARE Journal Conference, “Respiratory Care and Cystic Fibrosis,” held Therapy, Medicine, and Pediatrics; Patrick A Flume MD is affiliated with September 26-28, 2008, in Scottsdale, Arizona. the Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, South Carolina. Correspondence: Mary K Lester RRT, Department of Respiratory Ther- apy, Medical University of South Carolina, 169 Ashley Avenue, PO Box The authors have disclosed no conflicts of interest. 250906, Charleston SC 29425. E-mail: [email protected]. RESPIRATORY CARE • JUNE 2009 VOL 54 NO 6 733 AIRWAY-CLEARANCE THERAPY GUIDELINES AND IMPLEMENTATION Introduction patient so that there is the most effective clearance of airway phlegm. Airway-clearance therapies (ACTs) have long been con- sidered an important part of care of the patient with cystic Cystic Fibrosis Pulmonary Guidelines fibrosis (CF). This is based upon our understanding of the pathophysiology of CF lung disease. There is ineffective The Cystic Fibrosis Foundation established the Pulmo- mucociliary clearance1 and, from very early in life, there is nary Therapies Committee to develop guidelines for med- obstruction of the small airways by mucus.2 Mucociliary ications and therapies to maintain the lung health of patients clearance is an important defense mechanism of the air- with CF. Thus far, there are published recommendations ways, and patients are vulnerable to chronic infection of for medications used chronically10 and for ACTs.11 A sys- the airways. There is an exaggerated inflammatory re- tematic review of the published literature was used to de- sponse, with the airways containing bacteria, inflamma- velop these recommendations. An important realization in tory cells, and cellular breakdown products (eg, neutro- the development of the ACT guidelines was the lack of phil-derived deoxyribonucleic acid and filamentous actin large, long-term studies of airway clearance. It is not that (F-actin).3-6 All of this material increases the tenacity and there isn’t any evidence to support ACT for patients with stickiness of the airway secretions, and the airways be- CF; there are, in fact, a large number of studies, but most come further obstructed.7,8 Since the mucociliary clear- have small numbers of patients, are performed over short ance system isn’t working, it makes sense to use other periods of time (some only a single treatment), and many methods to help clear the airway secretions, if only to have no comparator. A prior systematic review concluded relieve the obstruction. In addition, these secretions con- that ACT increases mucus transport for the short-term, but tain bacteria and inflammatory mediators that continue to the authors could not draw conclusions about the long- injure the airways as well as recruit new inflammatory term effects or benefits.12 Another review noted that, de- cells. Therefore, clearance of airway secretions does more spite the “dearth of high-level evidence to support any than merely relieve obstruction; it also reduces the amount secretion clearance technique,” the lack of evidence does of infection and inflammation present in the airways. not mean lack of benefit.13 The Pulmonary Therapies Com- mittee felt that the existing evidence supporting ACT com- What Is Airway Clearance? pared to no therapies was fair in quality overall. They expressed concern that because ACT is so fundamental to ACTs are physical or mechanical means of facilitating CF treatment, a large controlled trial designed to explicitly the removal of tracheobronchial phlegm through the ex- prove the benefits of ACT could not be completed. They ternal and/or internal manipulation of air flow, and the determined that the overall benefit of ACT was moderate, evacuation of phlegm via coughing. One of the earliest based upon the various outcomes that had been studied forms of therapy, which continues to be a primary method, with a variety of therapies, including increased sputum is chest physiotherapy, or percussion and postural drain- production, increased lung function in the short-term, re- age. In 1959, British physiotherapist Jocelyn Reed first duced rate of decline of lung function, and increased ex- reported that “clapping and pressure vibrations, during long ercise tolerance. In the end, they recommended that some expirations, are the most effective forms of mechanical form of ACT be performed as a routine in all patients.11 stimulus to elimination of secretions in the treatment of There were other important findings in the systematic lung abscess, collapsed lobes, and bronchiectasis.”9 ACTs review that led to specific recommendations by the com- have evolved over the years, using imaginative strategies mittee. First, there weren’t any data to suggest that one such as high-frequency chest-wall compression using an type of ACT was better than any other. Second, patients inflatable vest connected to an air compressor, hand-held will express preferences, and it is believed that patients are expiratory vibratory devices, and, more recently, acoustic more likely to use therapies they believe to be beneficial. waves to vibrate the mucus from the airway walls. The Finally, aerobic exercise seemed to offer benefits to a respiratory therapist has an extensive menu of airway- regimen of airway clearance in addition to the other well- clearance modalities from which to choose (Table 1), each known benefits of exercise.14 with advantages and disadvantages. The intent of this pa- per is not to discuss the techniques for delivering the nu- Implementing the merous airway-clearance modalities; however, we have Airway-Clearance Therapy Guidelines included the instructions that we give to our patients and families on these therapies (Appendix). The intent is to Now that we have recommendations regarding ACT, we help guide the therapist in choosing an ACT that is appro- must address how to implement them in our CF clinics. priate for a CF patient at different stages of life. The We must find a way to communicate these recommenda- challenge for the therapist is to match the therapy with the tions to our patients and their families, and help them find 734 RESPIRATORY CARE • JUNE 2009 VOL 54 NO 6 AIRWAY-CLEARANCE THERAPY GUIDELINES AND IMPLEMENTATION Table 1. Methods of Airway Clearance Therapy Age Range Advantages Disadvantages Percussion and postural drainage All ages No cost/no equipment Requires caregiver Target specific areas of lung Tiresome Does not promote independence Blowing games 18 mo to 5 y Low cost Patient must have appropriate cognitive Prepares child for future spirometry ability Appropriate coughing Ն 18 mo Teaches to cover mouth None Promotes good hand-washing High-frequency chest compression Ն 2 y Promotes independence Expensive Portable Administer nebulized medications at same time Huff cough Ն 3–4 y Gentle coughing technique None Active cycle breathing technique Ն 4 y Independent, inconspicuous
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